By Hallie MacDonald
Q: Statistics report an estimate of 25 to 33% of people living with chronic illness also suffering from depression. What is the difference between situational or stress-related depression and chronic or major depression? Is one type more common for people with chronic illness?
A. First, it is essential to understand the differences between different types of depression. Clinical depression (also called Major Depressive Disorder) often refers to one or more serious depressive disorders that can occur with or without the person experiencing a specific stressor. The symptoms are generally more severe or last far longer in comparison to situational depression, and they usually will interfere with the person’s ability to function in their day to day life (work, school, family responsibilities,etc.). Common examples of clinical depression are:
Dysthymia - persistent depressive disorder - a low-grade depression lasting two or more years.
Seasonal Affective Disorder (SAD) - depression related to the reduction in natural light usually begins at the start of the fall/winter seasons.
Postpartum depression - can be debilitating and has various degrees of severity following pregnancy and giving birth.
Bipolar depressive disorder - the person experiences alternating periods of elation and depression.
A person experiencing a major depressive disorder will generally have five or more of the following symptoms and requires a medical diagnosis:
Sleep difficulties, changes to sleep patterns, including waking unusually early without desire or need.
The inability to feel joy or take pleasure in most or all daily activities.
Noticeable agitation or unusual slow movements - extreme lethargy
Feelings of worthlessness, self-loathing or self-hatred
Excessive feelings of guilt
Suicidal thoughts or beliefs that the world/family may be better off without you.
Significant weight loss or gain in a month without intention (5% or more of body weight)
In children - increased irritability
Commonly, major depressive disorders require medication as well as therapy to manage symptoms and learn coping skills. Clinical depression can be severe and requires the intervention of a medical professional. If you believe you or a loved one may be experiencing symptoms of clinical depression, contact a PCP or mental health professional for diagnosis and treatment.
Situational depression refers to symptoms of depression that are related to one or more specific stressors the person is experiencing. Situational depression is common after significant life changes such as divorce, death, job loss, etc.
Situational depression can cause emotional and behavioral symptoms that can look and feel very much like clinical depression. However, it is important to remember that it is reasonable to feel sad or anxious when life circumstances are difficult or overwhelming. The treatment for situational depression is supportive, such as seeking out organizations or support services that may help by giving and receiving support from others who have experienced similar stressors, such as; grief support groups or chronic illness support services.
Most people who are living with chronic illness experience situational depression or stress at different times during their lives. It is normal and expected. There is a period of mourning and feelings of grief as they adjust to the parts of their life that may be lost and while they adapt to a new self-image. This period of mourning is different for everyone. Finding a support group for people with related physical symptoms or similar disabilities is an essential tool because it offers the opportunity to feel validated and supported as well as to give validation and support to others in a similar situation. Just as crucial for people with a chronic illness is to develop coping skills to help with the everyday stress inherent in dealing with pain and illness regularly. Finding new activities or new ways to enjoy old activities can be an effective de-stressor, as well as continuing to connect with family and friends.
It is critical to recognize that more than one type of depression can be present at any time in a person’s life. Therefore anyone experiencing symptoms of depression must be screened by a medical professional. Suicidal thoughts experienced by you or a loved one requires immediate attention, contact the National Suicide Prevention Association at www.suicidepreventionlifeline.org or call the 24/7 hotline at 1-800-273-8255
Resource: National Association of Mental Illness https://www.nami.org/Blogs/NAMI-Blog/April-2017/Situational-Symptoms-or-Serious-Depression-What-s
Q: People living with dysautonomia disorders are commonly treated with BP medications, many of them with depression as a side-effect. How can medication-induced depression be treated? Is the treatment different than other types of depression? How can you tell if the depression is a side-effect or a symptom of the illness or a condition unrelated to dysautonomia?
A. Determining whether the symptoms are a side effect of the medication or are coming from another source requires an in-depth patient history. A physical exam and lab findings confirm the amount of medication in the bloodstream, as well as any additional intoxicants that may be present.
There is no specific treatment for depressive feelings brought on by medication use, other than switching to another medication. Usually, the side effects of most medications lessen or disappear as the body acclimates to it. If there is no improvement, then an alternative treatment will be needed. If the symptoms persist after four weeks, another source for the depression needs consideration.
Q: Anxiety is also prevalent with dysautonomia patients because so many of the symptoms can cause fear - high HR and palpitations, chest pain, fainting or near-fainting, etc. Anxiety can exacerbate the symptoms. Are there techniques that can help a person control their anxiety, or is medication necessary?
A. Many natural techniques can help reduce anxiety.
Practice deep breathing techniques. Take a deep breath in through the nose (breath in as slowly as possible), then breathe out steady and slow through pursed lips (position your lips as though you are going to whistle). It is important to keep the inhale and exhale even (counting helps) to avoid over-breathing that can cause hyperventilation. It will feel awkward at first, but if you practice, it will be a coping mechanism that is ready for you when you need it most. This technique also has the added benefit of being the most effective way to re-oxygenate your body and prevent hyperventilation.
Add a time-out to your day - listen to music, meditate, practice visualization, yoga if you can, do light exercise (whatever you can even from a sitting position).
Develop preventative habits. Eating well-balanced nutritious meals, avoid excessive sugars, and caffeine as both can add to anxious feelings. Give yourself a consistent sleep pattern by forming rituals that help you relax before going to bed.
Find reasons to laugh. Rent a comedy, stream stand-up shows by comedians, hang out with a friend who likes to laugh
Practice acceptance - you can’t control your illness, but you can control how you respond to it. Accepting what you can and can not do and finding ways to feel fulfilled and useful will add to your overall sense of well-being and reduce the feelings of anxiety.
Get involved. Reach out to your support network when you are feeling anxious about your illness. Explore what you are feeling and see if you can recognize a pattern or see triggers. Volunteer with the network if possible or find other volunteer opportunities. There are many opportunities to volunteer online. Getting out of your head is one of the best ways to deal with feelings of anxiety.
Medication is not usually necessary, and for people living with chronic illness, drugs for anxiety may be counterproductive or may not be possible. Consult with your physician if you feel you need medication.
Resource: Anxiety and Depression Association of America https://adaa.org/tips
Q: Dysautonomia, particularly POTS, is caused by a dysfunction in the autonomic nervous system, specifically the Sympathetic Nervous System (SNS) responsible for the fight or flight response in the body (the release of norepinephrine). What effect, if any, does this have on a person’s anxiety level or in causing depression?
A. Norepinephrine is a neurotransmitter associated with the fight or flight mechanism in the body and feelings of anxiety in the nervous system. Because dysautonomia creates an instability in the SNS, a person’s fight or flight response activates without an external need for that response. This instability is at the core of POTS symptoms. Physicians not familiar with the disorder can frequently assume the symptoms described are a result of the person’s inability to appropriately deal with anxiety or are living with depression.
Resource: Science Direct Journal Neuron Volume 87
"Norepinephrine and Corticotropin-Releasing Hormone: Partners in the Neural Circuits that Underpin Stress and Anxiety" by Yaijie Sun, Sarah Hunt, Panka Sah https://www.sciencedirect.com/science/article/pii/S0896627315006443
Q: Chronic illness requires the person to adapt to a new sense of self and to establish a new “normal” for their life. For example, a person's professional identity may need to change if they can no longer work. A person's role within their family as the "go-to" person may also need to change if they now need help from their family instead. How can family and friends help support the chronically ill person making this transition?
A. Loved ones of a chronically ill person should encourage or help (if wanted) the person find a support group or mental health professional that they can talk to without feelings of guilt or the need to censor their feelings or thoughts. Recognize that there are many parts of your loved one's adjustment that you will not be able to help directly. Be available and open to what they need and avoid telling them what they “should” feel. In a patient survey that DINET offered a few years back, members expressed what helped or hurt them in their encounters with family and friends. The number one thing cited as “help” was listening. The second helpful thing was believing the person about how they feel. Example, on Tuesday, your family member says they are too sick to get out of bed. But then later that week, they say they feel well enough to go out. Avoid questioning or discouraging their decision.
Dysautonomia is a disorder with a wide range of symptoms that can change quickly. Believing what they say and letting the person take the lead is empowering and validating.
The top two things that “hurt” patient encounters with family and friends were dismissive language such as “you don't look sick” or “think positive” and being told what they feel or should feel, such as “don’t think that way” or “you should feel grateful that things aren’t worse.”
Take the lead from the person. If they miss what they used to do for work, help them explore ways to use those skills in another capacity. Even the most physically active careers have skills that can translate to other uses without the physicality of the former activity. For example, a person who used to play sports may find a place for themselves in Special Olympics or through coaching. A business person may be able to volunteer with an organization in need of their business skills but without the demands of full time work.
In some cases, people find it too depressing to be on the fringes of what they used to do. In that case, help your loved one explore new hobbies or disciplines. Perhaps they aren’t up to attending classes, but you may suggest or help them find an online course they would find interesting. There may be new hobbies that you can do with the person. Whatever the action, be sure it is something the person wants to do or is receptive to your help. There is nothing wrong with making a suggestion but give the person the respect of truly hearing what they need from you.
People make the transition in their own time. There is no right or wrong way to go through it. You may have feelings of frustration that your loved one isn’t moving forward quickly enough or won’t let you cheer them up in the ways you think they should happily accept. Try and remember that this is their journey, and they have to find their way to their new “normal.” If you are a caretaker or close family member, and you are having feelings of sadness or anxiety about your loved one’s illness, seek out outlets for yourself. The chronically ill person can’t absorb your feelings about this transition. You can be honest while still being careful not to give responsibility to the sick person to make you feel better.
Resource: Help Guide: "Living well with a disability https://www.helpguide.org/articles/healthy-living/living-well-with-a-disability.htm
* Coming up: Part Two of Mental Health and Chronic Illness.
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